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Consent Inform

A consent inform is useful for the benefits of the patient and the physician. The name of the product should be mentioned if possible with the lot number for the tracability. In such case, the physicians using copies will bear all responsabilities in front of numerous huge complications.

Each information before hand is a clarification- After treatment it is an excuse !


I, ______________________________________________________, understand that I will
be injected with a preparation containing carbolic acid 5% mixed with arachidonic acid coming from peanuts oil in the area of ............................................ to get an early onset of lifting with late onset of skin rejuvenation and peeling.

The injected muscles temporarily will change of shape and increase their tonus without affecting them by any paralysis and/or atrophy .
Endopeel techniques injections are under medical responsibility of the physician, as a magistral preparation made by a specialized compound pharmacy will be used .
Endopeel techniques injections into the small muscles causes those specific muscles to stretch the area
(without being paralyzed), thereby improving the appearance of the wrinkles more in the static outlook than in the dynamic outlook .

I understand the goal is to lift, stretch and ,, iron,, the treated area giving it too a nice skin rejuvenation effect .

The effect is temporary, and re-injection is necessary within three to four months. It has been explained to me that other temporary and more long term treatments are also available.

The possible side effects of Endopeel injections include but are not limited to:
1. Risks: I understand there is a risk of swelling, rash, headache, local numbness, pain at
the injection site, bruising,ecchymosis and allergic reaction.
2. Infection: Infections are rarissime but can occur which in most cases are easily treatable but in rare cases a permanent scarring in the area can occur.
3. Most people have lightly swollen pinkish bumps where the injections went in, for a couple of
hours or even several days.
4. Ecchymosis can persist for several days or weeks.
5. Local numbness, rash, pain at the injection site.
6. Tightness or irritation of the skin.
7. Bruising is possible anytime you inject a needle into the skin. This bruising can last for
several hours, days, weeks, months and in rare cases the effect of bruising could be
8. Treatments: I understand more than one injection may be needed to achieve a satisfactory
9. Another risk when injecting carbolic acid around the eyes included corneal exposure because
people may not be able to blink the eyelids as often as they should to protect the eye. This
inability to protect the eye has been associated with damage to the eye as impaired vision,
or double vision, which is usually temporary. This reduced blinking has been associated
with corneal ulcerations. There are medications that can help lift the eyelid, however, if the
drooping is too great the eye drops are not that effective. These side effects can last for
several weeks or longer. This occurs in rarely.
10. I will follow all aftercare instructions as it is crucial I do so for healing.
As Endopeel is not an exact science, there might be an uneven appearance of the face with some
muscles more affected by the Endopeel techniques than others. In most cases this uneven appearance can be corrected by injecting more product in the same or nearby muscles. However in some cases this uneven appearance can persist for several weeks or months.
This list is not meant to be inclusive of all possible risks associated with Endopeel as there are both
known and unknown side effects associated with any medication or procedure.

Endopeel should not be administered to a pregnant or nursing woman.
The number of milliliters injected is an estimate of the amount of Endopeel products required to lift the
muscles. I understand there is no guarantee of results of any treatment. I understand the regular
charge applies to all subsequent treatments.

I understand and agree that all services rendered to me are charged directly to me and that I am
personally responsible for payment. I further agree in the event of non-payment, to bear the cost
of collection, and/or Court cost and reasonable legal fees, should this be required.

By signing below, I acknowledge that I have read the foregoing informed consent and agree to the
treatment with its associated risks. I hereby give consent to perform this and all subsequent Endopeel
treatments with the above understood. I hereby release the doctor, the person injecting the Endopeel products and the facility from liability associated with this procedure.

I have been informed by my physician more than three weeks ago during a first visit consultation which had a minimum duration of seventy five minutes.
I have got enough time to think about, ask many questions to my physician and the time between the first consultation as the first session of endopeel has been a minimum of three weeks .
I have not any more questions to ask my physician and I do agree fully to get the treatment as sessions.
I also do agree with the price of ............................................ which has been given by my physician more than three weeks ago during the first consultation.

Patient Signature______________________________________Date: _____

Physician Medical Assistent and/or Nurse Medical Testimonee